Body dysmorphic disorder (BDD) was first recognized as a distinct condition in 1987 by the American Psychiatric Association. This disorder's primary feature is preoccupation with an imagined or slight defect in one's physical appearance. This preoccupation may result in severe distress, impairment in social and occupational functioning, psychiatric hospitalization, suicidal ideation and suicide attempts. Patients with BDD may perform repetitive and compulsive behaviors in an attempt to mask, examine or change their physical appearance. These may include frequent mirror checking, excessive grooming and skin picking. While most persons are concerned with facial flaws, the focus can also be on other body parts. Up to 50 percent of BDD patients undergo surgical procedures to correct perceived defects. The true incidence of BDD is unknown, but it has been diagnosed in 1.9 percent of nonclinical patients and in 12 percent of psychiatric outpatients.

BDD has been considered an obsessive-compulsive disorder because some of the clinical features are similar (age of onset, intrusive thoughts and recurring behaviors); thus, the treatment of patients with BDD has involved the use of similar medications. Some preliminary study results suggest a limited response to selective serotonin reuptake inhibitors, but no controlled treatment studies have been published. Other agents, such as lithium, neuroleptics, trazadone and benzodiazepines, have not proved effective. Hollander and colleagues performed the first systematic double-blind, controlled study of the pharmacologic treatment of patients with BDD. They compared clomipramine (a potent serotonin reuptake inhibitor) with the active control desipramine (a selective norepinephrine uptake inhibitor).

Patients enrolled were between the ages of 18 and 65 who met the Diagnostic and Statistical Manual of Mental Disorders, 3d ed. rev. (DSM-III-R) criteria for BDD and suffered acute clinical distress or functional impairment as a result. Excluded were patients with DSM-III-R psychiatric disorders (e.g., bipolar disorder, major depression, psychosis). In addition, patients could not have taken other psychiatric medications before the onset of the study (for six weeks if taking fluoxetine, monoamine oxidase inhibitors or investigational drugs, and for two weeks if taking other psychiatric medications). After a placebo run-in period, patients were randomized to take clomipramine or desipramine for eight weeks. At the end of week 8, they were crossed over to the alternative medication for an additional eight weeks of therapy. Dosages were titrated for both medications by a treating psychiatrist at weekly follow-up visits. At each follow-up visit, the patients underwent a variety of assessments that included the BDD modification of the Yale-Brown Obsessive Compulsive Scale, the Clinical Global Impression Scale, the National Institute of Mental Health BDD Scale, the Schneier Disability Profile, the Fixity of Beliefs Questionnaire and the Hamilton Depression Rating Scale.

Of the 40 patients enrolled in the trial, 29 entered active treatment and were randomized. The average age was 34 years, with an almost equal number of men and women. The study revealed that clomipramine was superior to desipramine in decreasing BDD symptoms as measured by three different rating scales. This improvement included patient preoccupation with perceived body defects, symptom severity and repetitive behaviors. Also noted were lower scores on the Hamilton Depression Rating Scale in the patients taking clomipramine. Lastly, clomipramine was significantly more effective than desipramine in improving functional disability. This finding is notable because of the high level of functional disability associated with BDD patients.

The authors conclude that clomipramine is superior to desipramine in treating patients with BDD. They suggest additional studies to evaluate clomipramine versus placebo, further dosing adjustments and a longer term trial.

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